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How to Report Your QI Project

LUHS QUALITY IMPROVEMENT QUARTERLY REPORT
QUALITY IMPROVEMENT PROJECT (EXAMPLE)

Project Title: Patient Satisfaction with Privacy
Report Date: July 1, 2005
Department/Division/Unit/Committee: Patient Satisfaction Improvement Committee
Project Team Leader: Florence Nightingale                    Phone # 12345
Report Prepared by: Same                                                Phone #
Project Start Date: April 1, 2004
Anticipated/Actual End Date: October 1, 2005

PLAN
1.      Opportunity/Aim Statement with Measurable Goal
To ensure that our patients and families perceive that their personal privacy has been maintained. Our goal is to achieve a Press Ganey ranking of the 95^th percentile for privacy and to reduce privacy related patient complaints.

2.      Most Likely Causes
·        Semi private rooms
·        Significant traffic in/out of patient rooms
·        Patient transportation to other departments
·        Lack of caregiver awareness (ie knock before entering, introduce self, caregiver comments)

3.      Potential Solutions and Data Needed for Evaluation
·        Identify 3 pilot nursing units to test changes
·        Increase caregiver awareness – staff performance
·        Enhance patient comfort – patient reports; supplies utilized
·        Re-configure patient rooms to all private rooms (not feasible!)

DO
4.      Solutions Implemented
Change One – Staff Awareness:
·        Educational posters on all units
·        Signage on doors reminding to knock
·        Announce/Introduce self in patient encounters
·        Staff report held away from bedside

Change Two – Improve Patient Comfort:
·        Privacy curtains in private rooms
·        Provide extra large patient gowns
·        Provide slippers
·        Provide extra blankets for transport
·        Designate elevators for patient use only

STUDY
5A. Results – Attach data in graph format

5B. Data Analysis
After the first 90 days of implementation, the Press Ganey percentile ranking for privacy improved from 45% to 67%.   Patient/Family complaints related to privacy decreased from 12 per week to 6 per week.

ACT
6. Next Steps
·        Conduct patient focus group to learn about their expectations for privacy
·        Develop a service recovery program for privacy complaints
·        Explore opportunities for pilot units to share learnings with other departments
·        Identify incentives for active participation in privacy initiative
·        Add privacy question to Press Ganey ambulatory survey to determine if privacy is an issue in ambulatory areas
·         Further exploration of room re-configuration

Confidential: For Quality Improvement Purposes Only